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Instructions:

Upon completion of your complimentary telephone assessment and scheduling of your next appointment with Dr. Elina, you will be advised which forms are necessary for you to fill out.

Please select the appropriate PDF forms listed at right. Print and fill out each form according to instructions, and return your completed form(s) via US Mail to the address below (Mailing address is also printed on each form).

You must mail your forms at least 7 days prior to your next appointment in order for them to arrive in time to be reviewed by Dr. Elina. If your appointment is scheduled less than 7 days in advance, you may drop your forms off at the office in advance. In some cases, you will be advised to return your forms in person when you come in for your next appointment.

Thank you!

Dr. Elina Chernyak
Wholistic IntegraCare
PO Box 1717
Vail, CO. 81658

 

Forms

1. Consent to Care and Terms [PDF] (required)

2. Level I Client - Acute Medical Questionnaire [PDF]

3. Level II and III - Adult Medical Questionnaire [PDF]

4. HIPAA Privacy Notice [PDF] (required)

5. Medical Records Release Form [PDF]

6. Bio-Identical Hormones Questionnaire [PDF]

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DR ELINA CHERNYAK D.O.   |  P.O. BOX 1717   |   VAIL, COLORADO   |  drelina@wholisticintegracare.com

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